Antonella Tosti (editor) - Update in Cosmetic Dermatology
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This well-illustrated guide provides concise descriptions of the most frequently encountered cosmetic skin conditions and essential information on commonly employed treatment procedures. The book opens with a description of skin evaluation systems and then documents etiology, pathogenesis, diagnosis, and treatment for various conditions, including cellulite, acne, hirsutism, and striae distensae. The second part of the book provides step-by-step guidelines on a range of cosmetic procedures, such as botulinum toxin injection, cryosurgery, electrosurgery, and injection lipolysis. The advice provided will be invaluable for all physicians who intend to incorporate these procedures into their practices. The book will also be of interest to established specialists in cosmetic dermatology wishing to update their knowledge and to all general dermatologists and plastic surgeons required to answer the numerous questions posed by patients seeking to maintain or improve the quality of their skin.
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Antonella Tosti and Doris Hexsel (eds.) Update in Cosmetic Dermatology 2013 10.1007/978-3-642-34029-1_1 Springer-Verlag Berlin Heidelberg 2013
1. Skin Evaluation Systems
Dbora Zechmeister do Prado 1 , Amanda Stapenhorst 2, Carolina Siega 3 and Juliana Schilling de Souza 3
(1)
Independent Clinical Research Consultant, Porto Alegre, RS, Brazil
(2)
Department of Biomedicine, Brazilian Center for Studies in Dermatology, Universidade Federal de Cincias da Sade de Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil
(3)
Department of Research, Brazilian Center for Studies in Dermatology, Sociedade Brasileira de Profissionais em Pesquisa Clnica SBPPC, Porto Alegre, RS, Brazil
Dbora Zechmeister do Prado
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Abstract
Skin evaluation requires efficient and well defined methods to diagnose the skin conditions or diseases and also to follow treatment response. This chapter discusses recent progress and trends in the development of skin evaluations systems. Qualitative, semi-quantitative and quantitative methods can be used for such purpose. Qualitative methods include clinical examination, photographic documentation and qualitative scales. Semi-quantitative methods comprise grading and photonumeric scales, while quantitative methods are based in technologies that assess skin features or treatments results objectively. These methods offer enhanced clinical examination and can improve skin analysis, grading and standardizing results of daily practice and clinical research.
Core Messages
- Skin evaluation and its correct interpretation are of extreme importance for clinical diagnosis and also in research.
- Skin evaluation must start with a clinical exam and different assessment methods can be chosen according to the conditions or treatment results to be assessed.
1.1 Introduction
Skin evaluation and its correct interpretation are of extreme importance. Skin evaluation requires efficient and well-defined methods to diagnose the skin conditions or diseases and also to follow treatment response. These methods include the use of technological and validated resources, such as devices and scales.
In this chapter, qualitative, semiquantitative, and quantitative skin evaluation methods will be discussed. The qualitative methods are subjective and range from physical examination to the clinical evaluations, including the photographic documentation. The semiquantitative methods include the grade and photographic scales, which were created to facilitate the rating of specific skin conditions. Quantitative methods are based on objective measurements of certain skin features, such as photodamage signs, pigmentation, sebum, and hydration.
1.2 Qualitative Evaluation of Skin
1.2.1 Clinical Exam
The dermatological exam begins with physicians questions to the patients about their skin condition and related symptoms. Demographic data, including age, gender, and race, besides previous conditions, medications, and family medical history are important elements. The skin should be always evaluated in a well-illuminated place, with direct light. The exam is performed from head to toe, including hair, mucosa, nails, and ganglions. It is also recommended using instruments, such as dermatoscope, Woods lamp, and digital photography, according to each patients needs.
1.2.1.1 Dermatoscope
The dermatoscope is a magnifier used to diagnose skin pigmentation disorders and to distinguish benign from malignant lesions, including melanomas [). 
Fig. 1.1
Digital dermatoscope, used to diagnose pigmentation disorders
1.2.1.2 Woods Lamp
Woods lamp is an ultraviolet light used to diagnose some hair and skin conditions (Fig. ) such as melasma, vitiligo, and porphyria. When fluorescence is applied onto the skin, the epidermal pigment is highlighted, but the same does not happen to the dermal pigment. 
Fig. 1.2
Woods lamp, an ultraviolet light used to diagnose hair and skin conditions
1.2.1.3 Photographic Documentation
Photographic assessment of the skin can be important to record patients medical history, to follow up patients, and also when a second opinion is sought. Photographic assessment significantly improves patients understanding on their diagnostic and treatment progression [].
Before acquiring the images, it is suggested to ask patients to sign an informed consent form for photographs, especially if the patient can be recognized. Define high-quality standards to create and maintain photographic patient records as well as to guarantee and maintain patient anonymity and confidentially [].
Standard photographic methodology is recommended to collect and store patients images. The images should be always taken using the same parameters, such as camera settings, patient position, and light. Some pictures require a point-source flash, while others require elimination of shadows caused by using a ring flash [].
The minimum setup needed to document face and body is composed by digital camera; proper light source; appropriate computer to store, analyze, and display the digital files; and a trained photographer.
The photographer is responsible for controlling the standards previously defined when taking the photographs. Moreover, he/she must be patient, especially early on to keep the patient calm to achieve good quality images.
Most of the current digital cameras available in the market offer high resolution. For dermatological use, a resolution of four million pixels is enough []. Low-resolution images should be avoided.
Light source positioning is crucial for the photograph quality. Wrong positioning of the lights can create shadows, compromising the skin evaluation. The background must be neutral, monochromatic, and non-reflective, preferably dark. A dark and opaque background provides greater control of the illumination over the subject. The positioning of light source should be the same at all time points for the same subject.
The relatively equal position of the subject to the camera enables the acquisition of the same field size before and after treatment. Makeup, jewelry, and clothing that might interfere the images should be removed. For facial photographs, usual positions are front, oblique view (45), and lateral (left and right), and a neutral face expression during the shoot is required (Fig. ). 
Fig. 1.3
Photographic studio
A standardized setup and imaging procedure is recommended for better correlations between before and after treatment images. Further correlation between the two images could be accomplished using anatomical landmarks. The after treatment image should be compared to the before image immediately after acquisition for consistency and to retake if necessary.
Some objective imaging tools were developed to standardize the photographic position and to assure the photographic quality. Companies like Canfield ScientificTM and FotoFinder SystemsTM developed a series of methods and equipments to obtain standardized, reproducible, serial medical photographs and documentation reducing the photographic variables of images.
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